title: Current application of National Institute for Health and Clinical Excellence (NICE) guidance in the management of patients with severe psoriasis: a clinical audit against NICE guidance in seven National Health Service specialist dermatology units in England.
abstract: BACKGROUND
  Psoriasis affects 1-2% of the U.K. population, with 20-30% of those affected having severe psoriasis managed with systemic therapies. Biological agents are a useful option when other systemic therapies have failed. The National Institute for Health and Clinical Excellence (NICE) in the U.K. has published three sets of guidance relating to the use of biological agents.
  
  
  OBJECTIVE
  To establish whether biological agents were being used in line with NICE guidance.
  
  
  METHODS
  The study was conducted in seven specialist dermatology units, and involved the retrospective collection of data from patients treated with biological agents since the introduction of the NICE guidance.
  
  
  RESULTS
  In total, 176 patients with 212 episodes of treatment were included in the study. Biologics were started for appropriately severe disease in 85% of cases (n = 180) and only after failure, intolerance or contraindication to standard systemic therapies in 97% of cases (n = 206). Etanercept was discontinued appropriately in responders before week 24 in only 12% (five of 60 responders). Across all agents, 40% (72 of 178 with continuity status) were continued on treatment despite not achieving an adequate response according to NICE criteria.
  
  
  CONCLUSIONS
  In the seven sites audited, compliance with national guidance was entirely appropriate in terms of therapy initiation; however, the requirement to discontinue etanercept in responders was rarely followed. Similarly, discontinuation of biologicals in nonresponders was not routine practice. This may indicate a reluctance of both patients and clinicians to withdraw an at least partly effective therapy from these refractory patients.
authors.affiliation: Department of Dermatology, Whipps Cross Hospital, London, UK. anthony.bewley@whippsx.nhs.uk
authors.forename: A
authors.initials: A
authors.lastname: Bewley
authors.forename: R
authors.initials: R
authors.lastname: Cerio
authors.forename: M
authors.initials: M
authors.lastname: Clement
authors.forename: S
authors.initials: S
authors.lastname: Hunt
authors.forename: T
authors.initials: T
authors.lastname: Lucke
authors.forename: R
authors.initials: R
authors.lastname: Ratnavel
authors.forename: S
authors.initials: S
authors.lastname: Walton
authors.forename: F
authors.initials: F
authors.lastname: Percival
mesh_terms: D000893:Anti-Inflammatory Agents / Q000627:therapeutic use*; D001688:Biological Products / Q000627:therapeutic use*; D054869:Clinical Audit; D003695:Delivery of Health Care / Q000592:standards; D004739:England; D019983:Guideline Adherence; D006801:Humans; D017410:Practice Guidelines as Topic; D011565:Psoriasis / Q000628:therapy*; D012189:Retrospective Studies; D013222:State Medicine / Q000592:standards
chemical_list: D000893:Anti-Inflammatory Agents; D001688:Biological Products